The nurse is caring for a postpartum client who delivered 5 hours ago, and has saturated a perineal pad with clots within the last 15 minutes.Which action is most important for the nurse to implement?
Assess the vital signs.
Increase IV infusion rate.
Notify the healthcare provider.
Massage the fundus.
None
None
The Correct Answer is D
Assessing vital signs is important but not the most immediate action for heavy postpartum bleeding. It provides information about the client's current status but does not address the bleeding directly.
Choice B rationale
Increasing the IV infusion rate can help manage blood loss by maintaining blood volume, but it is not the first action to take when managing postpartum hemorrhage.
Choice C rationale
Notifying the healthcare provider is important but secondary to addressing the immediate cause of the bleeding. The provider will need information about the client's status and the actions taken to manage the situation.
Choice D rationale
Massaging the fundus is the most immediate and effective action to reduce postpartum hemorrhage. It stimulates uterine contractions, which helps to clamp down on the blood vessels and stop the bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Increasing the infusion rate of magnesium sulfate without medical approval is not appropriate. The prescribed rate should be followed unless the provider orders a change.
Choice B rationale: Assessing the client’s deep tendon reflexes and respiratory rate before administering magnesium sulfate is crucial. Magnesium sulfate can depress the central nervous system and respiratory function, so baseline assessments are necessary to identify any adverse effects early.
Choice C rationale: Stopping the infusion for variable decelerations is not the initial step. Variable decelerations may need to be addressed, but it is not the priority action before starting magnesium sulfate.
Choice D rationale: Administering an antihypertensive medication is important if the blood pressure remains elevated, but it is not specified as required before starting magnesium sulfate.
Correct Answer is C
Explanation
Choice A rationale
While bulb syringe use is important for clearing the newborn's airways, it is not the immediate priority during the fourth stage of labor. This information can be provided later during routine newborn care education.
Choice B rationale
Newborn screening tests are important for identifying potential health issues, but the fourth stage of labor is focused on stabilizing the mother and infant and initiating breastfeeding. Screening information can be shared during the postpartum period.
Choice C rationale
Techniques to breastfeed are critical information to provide during the fourth stage of labor as it helps establish successful breastfeeding early on. This support can enhance maternal-infant bonding and promote breastfeeding success.
Choice D rationale
Circumcision care is relevant for parents who choose to circumcise their infant, but it is not the immediate priority during the fourth stage of labor. This information can be provided during subsequent postpartum visits.
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